Standard Operating Procedure for Data Entry and Source Documentation in Clinical Phase of BA/BE Studies
Department | BA-BE Studies |
---|---|
SOP No. | SOP/BA-BE/091/2025 |
Supersedes | SOP/BA-BE/091/2022 |
Page No. | Page 1 of 10 |
Issue Date | 17/04/2025 |
Effective Date | 20/04/2025 |
Review Date | 17/04/2026 |
1. Purpose
To establish a standardized approach for the documentation of clinical data at source and its subsequent entry into Case Report Forms (CRFs) or electronic systems during the clinical phase of Bioavailability/Bioequivalence (BA/BE) studies, ensuring traceability, accuracy, and compliance with ALCOA+ principles.
2. Scope
This SOP applies to all clinical personnel involved
in source data documentation, CRF/eCRF data entry, data verification, and clinical quality assurance during the conduct of BA/BE studies.
3. Responsibilities
- Study Nurse: Documents observations and procedures in real-time on source documents.
- Clinical Research Coordinator (CRC): Verifies completeness and consistency of source documents and performs CRF data entry.
- Principal Investigator (PI): Reviews and signs off on key clinical data and source-CRF correlation.
- QA Officer: Audits data trail from source to CRF and ensures ALCOA+ compliance.
4. Accountability
The Study Director is accountable for ensuring that all source documents and CRFs are handled according to applicable regulatory guidelines, and that data integrity is maintained throughout the clinical phase.
5. Procedure
5.1 Source Documentation
- Use only approved source templates pre-printed with study ID, subject ID, and visit date.
- Document the following at source:
- Volunteer identity and informed consent status
- Vital signs
- Pre- and post-dose assessments
- Adverse events
- Dosing records
- Sample collection times and personnel
- All entries must be:
- Legible
- Signed and dated
- Made in blue or black ink
- Corrections must follow GCP standards: strike through, write correct entry, date and initial.
5.2 CRF Data Entry
- Transfer data from source to CRFs after each study activity or at end of day.
- Ensure that:
- CRF data matches the source exactly
- Blank fields are marked “NA”
- Corrections follow SOP for CRF amendments
- Document and explain any discrepancies using Annexure-1: Source-CRF Discrepancy Log.
5.3 Electronic Data Capture (eDC)
- If using eCRFs, enter data directly into the validated system with individual login credentials.
- Audit trails must remain intact and accessible for inspection.
5.4 Quality Control and Review
- CRC must perform cross-checks of 100% of critical fields (e.g., date/time of dosing, AE records).
- PI to review and sign off on CRFs and summaries (Annexure-2: CRF Verification Log).
5.5 Storage and Confidentiality
- Store source documents in subject-wise files secured in a locked room with access logs.
- Electronic source and CRFs must be password protected and regularly backed up.
6. Abbreviations
- BA: Bioavailability
- BE: Bioequivalence
- CRF: Case Report Form
- eCRF: Electronic Case Report Form
- PI: Principal Investigator
- CRC: Clinical Research Coordinator
- QA: Quality Assurance
- ALCOA+: Attributable, Legible, Contemporaneous, Original, Accurate + Complete, Consistent, Enduring, and Available
7. Documents
- Source-CRF Discrepancy Log – Annexure-1
- CRF Verification Log – Annexure-2
8. References
- ICH E6(R2) – Good Clinical Practice
- 21 CFR Part 11 – Electronic Records
- Schedule Y – Drugs and Cosmetics Rules
9. SOP Version
Version: 2.0
10. Approval Section
Prepared By | Checked By | Approved By | |
---|---|---|---|
Signature | |||
Date | |||
Name | |||
Designation | |||
Department |
11. Annexures
Annexure-1: Source-CRF Discrepancy Log
Date | Subject ID | Field | Source Value | CRF Value | Resolution | Reviewed By |
---|---|---|---|---|---|---|
17/04/2025 | VOL-091 | Pulse | 78 | 87 | Corrected in CRF | Dr. Arvind Shah |
Annexure-2: CRF Verification Log
Subject ID | Date Reviewed | Reviewed By | Remarks |
---|---|---|---|
VOL-091 | 17/04/2025 | Dr. Arvind Shah | Complete and accurate |
Revision History:
Revision Date | Revision No. | Details | Reason | Approved By |
---|---|---|---|---|
12/01/2022 | 1.0 | Initial SOP | GCP Compliance | QA Head |
17/04/2025 | 2.0 | Added ALCOA+ reference, clarified eCRF and source reconciliation | Audit Observation | QA Head |